Adaptation and validation of the Ugandan Primary Care Assessment Tool

Background Health systems based on primary health care (PHC) have better outcomes at lower cost. Such health systems need regular performance assessment for quality improvement and maintenance. In many low- and middle-income countries (LMICs), there are no electronic databases for routine monitoring. There is an urgent need for valid and reliable tools to measure PHC performance. Aim This study aimed to adapt and validate the Primary Care Assessment Tool (PCAT) in the Ugandan context. Setting The experts that participated in the Delphi process were recruited from almost all over the country. Methods The study utilised a Delphi process with a panel of 20 experts (14 district health officers, 4 academics in primary care and 2 ministry of health [MOH] technical staff) who responded to iterative rounds of questionnaires in order to reach consensus (defined as > 70% agreement). Results Consensus was reached after two rounds of the Delphi. In round one, four items in the comprehensiveness domain (services available) were removed and five items needed rephrasing. A new domain on person-centredness with 13 items was suggested. In round two, the new domain with each and every single one of its items and the items for rephrasing all achieved consensus. The final Ugandan version of the PCAT (UG-PCAT) has 12 domains and 91 items. Conclusion The South African Primary Care Assessment Tool (ZA PCAT) was adapted and validated with an additional domain on person-centredness to measure primary care performance in the Ugandan context, and can now be used to measure the quality of core functions of primary care in Uganda. Contribution The PCAT could fulfil the need for such a tool in a wider LMIC context. The UG-PCAT will be used to measure the quality of these core functions in Uganda and to assist with the improvement of PHC.


Introduction
Health systems based on primary health care (PHC), with well-established and functioning primary care, have better health outcomes at lower cost. 1,2,3 The declaration of Alma Ata in 1978 was the first global consensus to articulate the role of PHC in health systems with an ambitious goal of 'Achieving Health for All' by the year 2000. 4 Although many global, regional and national stakeholders have attempted to promote and implement PHC, there is still significant inequity in health, with almost half of the world's population having no access to high quality PHC. 5 As a result, there is a high prevalence of unaddressed individual and population health needs in many parts of the world.
improvement. Therefore, valid and reliable tools are needed to measure primary care performance to identify performance gaps which can then be targeted for improvement.
The global need to measure the performance of PHC has led to the development and validation of several tools and frameworks, which include the Primary Care Assessment Tool (PCAT), 10 the Quality of Outcomes Framework (QOF), 11 the Primary Health Care Performance Initiative (PHCPI) framework, 12 the European Primary Care Monitoring Framework (EPCMF), 13 and the Patient Centred Primary Care Measure (PCPCM). 14 The latest global approach to PHC performance measurement is the WHO framework embedded within the PHC theory of change as described in the PHC operational framework. 15 These tools and frameworks have been used to measure PHC performance in different countries around the world. 16,17 Such tools should effectively measure the core functions of primary care through patient surveys as recommended by WHO. 18 The core functions of primary care are defined as first-contact accessibility, comprehensiveness, continuity, coordination, and person-centredness. Among all these tools and frameworks, the PCAT has been widely used to measure PHC performance focusing on the core functions as experienced by patients.
There is need for robust evidence to guide primary care policy and resource allocation, particularly in low-and middleincome countries (LMICs) struggling with weak health systems. Most studies on PHC have focused on policy, payment systems, workforce, community engagement, frameworks for performance management, provider competence, provider motivation, provider-patient relationships, and personcentredness as well as comprehensiveness of care. 19 Most measurement indicators focus on inputs and outputs, particularly coverage and population health for prioritised conditions such as human immunodeficiency virus (HIV), tuberculosis (TB), malaria and maternal mortality, with relative neglect of the broader system, service delivery and final outcomes. 20 Primary health care is a complex system and there is no single tool that can measure all the domains included in its framework. Different tools have been developed to measure particular components of PHC, and the PCAT measures the core functions of primary care. 15 Countries with well-established health information systems and large electronic databases can more easily monitor the performance of their primary care systems. This is not so easy in LMICs, where there are often no electronic medical records and minimal routinely collected electronic data. In LMICs, routine health information systems have been implemented to collect health information at regular intervals. 21 Studies have found poor data quality, given the diverse methods and tools used in its collection. 22 Therefore, data may be difficult to rely on as a basis for decision and policy-making. Additionally, such health information is collected with negligible, or no involvement of the people served. In measuring the quality of health services, particularly primary care, the key functions should be assessed from the patients' perspective, and the PCAT tool allows such an approach. 10 The PCAT has been used in several regions of the world to assess the quality of PHC services and some core primary care functions. 17 However, the PCAT needs to be adapted to the local context for validity and reliability given the cultural and contextual differences that exist among populations and health systems around the globe. It is also important that tools to measure PHC performance are regularly updated and aligned with new ideas, policies and guidelines by global bodies such as the WHO. This study aimed to adapt and validate the South African version of the PCAT to the Ugandan primary care context for use in measuring primary care performance in a district health system (DHS).

Study design
The Delphi technique, with a panel of experts, was used to adapt and validate the South African Primary Care Assessment Tool (ZA PCAT) for the Ugandan context.

Setting
In Uganda, primary care is provided through the DHS that is composed of the Village Health Team (VHT) at level I, followed by different levels of Health Centres (from levels II to IV), all operating under the Health Sub-District (HSD) leadership and governance. The general hospital then forms the apex of the DHS for these primary care facilities. The Ministry of Health (MOH) formulates PHC policies and provides stewardship on their implementation and overall functioning of the health system. Primary care providers include nurses, midwives, dispensers, clinical officers (mid-level clinicians) and non-specialist doctors referred to as medical officers. Due to the scarcity of doctors, primary care services are mainly provided by clinical officers, nurses and midwives, with support from community health workers. This primary care system lacks gatekeeping and therefore is characterised by patients bypassing the lower-level health facilities to seek care in hospitals and specialised centres.

Selection of the expert panel
A panel of 30 experts was purposively selected as recommended in literature. 23 The selection was based on their conceptual understanding of primary care as well as the Ugandan context. Experts included family physicians (because of their specialist training in primary care), district health officers (because they oversee the district primary care system), primary care academics (because they are familiar with updates and trends in primary care), and technical personnel in the directorate of clinical services in the MOH (because they are familiar with primary care policy formulation and implementation). The selected experts were contacted by telephone and invited to participate in the study. All the contacted experts agreed to participate in the panel. The final panel included 10 family physicians, 14 district health officers, 4 academics and 2 technical staff from the MOH.

The South African Primary Care Assessment Tool
The South African version of the PCAT (ZA PCAT) measured 11 primary care domains (Table 1) with 82 items. The tool had an additional three domains on the extent of affiliation to the primary care facility (6 items), self-assessment of overall health status (2 items), and respondents' socio-demographic characteristics (12 items). Each item in the main domains was scored on a 4-point Likert scale (4 -definitely, 3 -probably, 2 -probably not and 1 -definitely not). Each item also has an additional option of 'not sure/don't remember'.

Consensus definition and achievement
Consensus was pre-defined as 70% agreement among the experts and four rounds were planned as follows:

Round 1:
The questionnaire was sent to the panel by email and a follow up telephone call prompted them to complete it. For each item, two questions were asked: (1) whether the topic addressed in the item was relevant to the Ugandan context and therefore should be kept, and if not relevant, then the experts were asked to explain why and suggest an equivalent replacement item, and (2) whether relevant items were phrased appropriately and if not, to suggest alternative wording. Experts were also asked to confirm the relevance of the domains and to suggest any new domains or items.

Round 2:
The items for which consensus was not achieved in round 1, together with any new suggested domains or items, and any suggested rephrasing of items were compiled into a new questionnaire. This questionnaire was again emailed to the panel. Any qualitative feedback and percentage scores for the items from round 1 were also included. The experts were asked to provide further feedback on these items. At the end of each section, the experts were again asked to give any additional qualitative feedback and to suggest any new domains and/or items relevant to the Ugandan context.

Round 3:
This was planned in the same way as round 2.

Round 4:
A face-to-face workshop was planned for the panel to reach a final decision on any items that did not achieve consensus in rounds 1-3. The nominal group technique (NGT) was identified as a useful process that could be used in the workshop.

Ethical considerations
This study was approved by the Health Research Ethics Committee at Stellenbosch and the Makerere University School of Medicine Research and Ethics Committee. Written

Domain Definition Number of items
First contact (utilisation) Utilisation of primary care services when a need for care arises. First contact refers to the primary care services being responsible for assisting the person in need of care to enter the health care system for each non-referred provision of healthcare.

3
First contact (access) Care is first sought from accessible primary care services when a new health or medical problem arises. Primary care serves as the usual entry into the health care system.

5
On-going care Longitudinal use of a regular source of care over time regardless of the presence or absence of disease or injury. A health care home is then established where the person seeks continuous care building a long-term relationship with the provider as well as fostering mutual understanding and knowledge of each other's expectations and needs.
9 Coordination (health system) Linking of health care visits and services so that patients receive care for all their health problems, physical as well as mental. Primary care systems taking responsibility and obligation to transfer information to and receive it from other sources that may be involved in the care of the patient.
10 Coordination (information system) Availability of mechanisms to communicate information and use of that information in the person's care plan. 3 Comprehensiveness (services available) Availability of a wide range of essential health services in primary care that promote and preserve people's health as well as providing care for illness and disability.

23
Comprehensiveness (services provided) Appropriate provision of health care and essential health services in primary care across the entire spectrum that promote and preserve people's health as well as providing care for illness and disability.

9
Family-centredness Recognition of a family as a major participant in the assessment and management of the patient. Family-centred primary care recognises and incorporates knowledge of the family context (resources, risk factors and social factors) into the planning and delivery of primary care services.

3
Community orientation Care that recognises the primary care needs of defined population. The effective delivery of services to individuals and communities is based on an understanding of their needs and the integration of their perspectives in the provision of health care. Primary care providers contribute to and participate in community assessment, health surveillance, monitoring and evaluation.

6
Cultural competence Health care that respects the beliefs, interpersonal relationships, attitudes and behaviours of people and their influence on health. Services are designed to be acceptable to people distinguished by common values, language, heritage, and beliefs about health and disease within the communities served. The views of these groups should be determined and incorporated into decisions involving policies, priorities and plans related to the delivery of health care services.

PHC team
Availability of members of a multi-disciplinary PHC team such as social workers, therapists or community health workers.

6
Health assessment Personal perception of one's own health status. 2 Socio-demographic characteristics Socio-demographic profile of the respondents. informed consent was sought from the experts before their participation in the Delphi process. The experts were informed that their participation was voluntary and that they can withdraw their participation at any stage of the process with no negative consequences. S20/04/103 and REC REF 2020-164. 26 May 2020 and 15 September 2020.

Results
The final panel that actually engaged with the Delphi process consisted of seven family physicians, seven district health officers, four primary care academics, and two MOH technical staff in the directorate of clinical services. All 20 experts completed two rounds of the Delphi process, after which consensus was achieved on all domains and items.

Round 1
The consensus of the panel was to retain all 11 domains. Within these domains, consensus for retention was achieved for 73 items. There was consensus to remove the following four items from the domain of comprehensiveness (services available): • Checking to see if anyone in your family qualifies for any social grants, for example, old age pension, child support grant, disability, TB. • Suggestions for nursing home care for someone in your family. • Help with food supplements such as Ensure or food parcels. • Access to termination of pregnancy services at or via your facility, if required.
Eight items required re-phrasing from the socio-demographic characteristics, comprehensiveness, and cultural competence domains ( Table 2).
Two expert panel members suggested an additional new domain 'person-centredness' and also suggested 13 items for the new domain based on a literature. 26 All the rephrased items and the items suggested for the new domain were included in a new questionnaire for round 2 of the Delphi. Table 3 and Table 4 show the results of round 2. Table 3 shows items that were rephrased and on which the panel reached consensus in round 2.

Round 2
The new domain person-centredness with all its items achieved consensus when presented to the panel of experts ( Table 4). The 3rd and 4th rounds of Delphi were not done because all domains and items achieved consensus for inclusion in rounds 1 and 2. The final Ugandan version of PCAT (UG-PCAT) (published as a supplement to this article) has 12 domains and 91 items.

Discussion
The UG-PCAT was adapted and validated through a 2-round Delphi despite the originally planned four rounds and an NGT. Four items were removed, six items were re-phrased,  There is no Dutch medicine in Uganda and special beliefs about health care would be difficult to define.
What is your home language? What is your local language? Local language is a more appropriate wording for the Ugandan context.
What is the highest grade that you completed at school? What is the highest education level you completed at school?
The change was done to cater for the nomenclature of education grading in Uganda Which of the following best describes your dwelling? Which of the following best describes your home? This was rephrased to match the easily understood word 'home'.
PAP, Papanicolaou; CHC, community health centre. and a new domain on person-centredness with 13 items was added. The UG-PCAT is therefore very similar to the ZA-PCAT, and this may be a reflection of the broad similarities in context. The removed items, in the domain of comprehensive services available, reflect a different model of care, which does not include such services. This is because of the differences in approach to social services and legality of termination of pregnancy. Eight items were rephrased to suit the Ugandan vocabulary, culture and context.
Termination of pregnancy is illegal in Uganda and is only done for medical indications when three senior doctors agree. 27 As one doctor must be a gynaecologist, this decision cannot be made in primary care settings. The Ugandan human resource policy allows employment of gynaecologists in secondary and tertiary care hospitals. Social grants, food supplementation and food parcels are not offered in the Ugandan setting. Social grants were a new phenomenon with the coronavirus disease 2019 (COVID-19) crisis, where certain vulnerable groups were offered food and money during lockdown. 28 Care for patients in nursing homes is not possible as such homes are non-existent in both public and private settings. In adapting the tool, there is a tension between removing items that are not contextually relevant and removing items that may be considered essential to the measurement of that domain from a global PHC perspective. In our view, the removal of these items should not significantly weaken the reliability of the measurement of comprehensiveness in our context.
Adaptation and validation of PCAT tools has previously been done using panels of experts comprising primary care practitioners, family physicians, policymakers, health system managers, and in some cases health consumer organisations and patients' representatives. 29,30,31 This same approach was used with the experts assessing the content validity of domains and items rather than the construct validity. This approach of using multiple stakeholders caters for all perspectives within the complexity of primary care delivery.
The process has usually involved a series of Delphi rounds with some including the NGT to achieve final consensus. 30,31 This was not necessary in this study, maybe because the process in South Africa had already adapted the PCAT into the African context. Some authors have also utilised focus groups particularly for the rephrasing of items. 31 The Kenyan version (KE-PCAT), also adapted from the ZA PCAT, is similar to the UG-PCAT with only three items removed and two rephrased. 32 The same three items removed from the Kenyan version were also removed from the UG-PCAT and were from the same domain of comprehensiveness (services available). Therefore, other than the added person centredness domain to the UG-PCAT, the two versions are very similar. This helps to confirm the validity of the tool and the changes made for the East African context.
The original PCAT and the ZA-PCAT measure the core primary care functions of first contact access, continuity, comprehensiveness and coordination, but not personcentredness. Addition of the person-centredness domain to the UG-PCAT allows it to measure all the core functions as recently defined by the WHO. 18 All the 13 items to measure the person-centredness domain were adopted from the Physician-Provider Communication Behaviours scale that was developed in neighbouring Kenya. 26 All the items in the person-centredness domain achieved consensus for inclusion in only one round of the Delphi. Therefore, they are likely to be valid for the Ugandan context, which is very similar to the Kenyan one. However, they may need adaptation and validation in other African settings before use.
The UG-PCAT is quite lengthy compared to other versions and requires significant time to complete. This may compromise the feasibility of its use, particularly in busy primary care settings. However, it may also be possible to exclude the domains on teamwork, cultural competence, family-orientation and community-orientation, if the tool is streamlined to measure only the core functions of primary care as per the WHO measurement framework. 18 The UG-PCAT therefore provides exactly the kind of tool envisaged by the WHO for measuring the core functions of primary care.
The process of adaptation and validation of the ZA-PCAT in Malawi involved exploratory factor analysis (EFA) with significant exclusion of both domains and items. 30 Only 29 items remained in the Malawian version of the PCAT. Such reduction of domains and items makes the tool easy and quick to use, but also carries a high risk of losing the psychometric properties of the original version.
Performing EFA on a tool that was already reliably constructed was probably unnecessary and resulted in a version that would be difficult to use outside of Malawi. The results of the Malawian PCAT will also be difficult to compare to results from the South African, Kenyan and Ugandan versions.

Limitations
It is important to note that the PCAT does not necessarily measure what is important to the patients or users of health services, but their perception of the quality of primary care services. Therefore, other tools will be required to be responsive to patient satisfaction with services.

Recommendations and implications
The UG-PCAT can now be used to measure the core functions of primary care in Uganda. The researchers plan to implement this within the rural Tororo district and investigate whether the measurements assist the district health services to improve quality of service delivery. Other researchers in the Ugandan context can also use the UG-PCAT.
Although all the domains were retained in this version of the UG-PCAT, it makes sense to focus on the domains that measure the core primary care functions as defined by the new WHO measurement framework. 18 This will align the tool with the WHO framework and make it an attractive option for governments and health services to use in the African context. At the same time, this will also shorten the tool and make it more feasible to use.
Thought should be given to the creation of a PCAT tool that can be used across multiple countries in the region or even for sub-Saharan Africa as a whole. The South African, Kenyan and Ugandan versions of the PCAT are sufficiently similar to enable this.
Other versions of the PCAT (the managers' and providers' versions) should also be adapted and validated for use in the Ugandan context. These will help to comprehensively measure the performance of primary care from the perspectives of other key stakeholders in the delivery of quality primary care.

Conclusion
The users' version of the ZA-PCAT was adapted and validated to measure primary care performance in the Ugandan context. A new domain on person-centredness was added. The UG-PCAT is now able to measure the core functions of primary care as per the new WHO measurement framework. The PCAT could fulfil the need for such a tool in a wider LMIC context. The UG-PCAT will be used to measure the quality of these core functions in Uganda and to assist with the improvement of PHC.